Staff experiences,perceptions of care,and communication in the intensive care unit during the COVID-19 pandemic in Australia

BackgroundIn 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission.AimThe aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale.MethodsThis was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis.FindingsFour major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods.ConclusionThe results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.     

Mental well-being of intensive care unit nurses after the second surge of the COVID-19 pandemic: A cross-sectional and longitudinal study

ObjectivesTo determine the impact of the second surge of the COVID-19 pandemic (October 2020 to June 2021) on mental well-being of intensive care unit nurses and factors associated with mental health outcomes.MethodsAn online survey was available for Dutch intensive care unit nurses in October 2021, measuring mental health symptoms; anxiety, depression (Hospital Anxiety and Depression Scale), and post-traumatic stress disorder (Impact of Event Scale-6). Additionally, work-related fatigue was measured using the Need For Recovery-11 questionnaire. Previous data from the first surge (March until June 2020) were used to study mental well-being longitudinally in a subgroup of intensive care unit nurses. Logistic regression analyses were performed to determine factors associated with mental health symptoms.ResultsIn total, 589 nurses (mean age 44.8 [SD, 11.9], 430 [73.8 %] females) participated, of whom 164 also completed the questionnaire in 2020. After the second surge, 225/589 (38.2 %) nurses experienced one or more mental health symptoms and 294/589 (49.9 %) experienced work-related fatigue. Compared to the first measurement, the occurrence of mental health symptoms remained high (55/164 [33.5 %] vs 63/164 [38.4 %], p = 0.36) and work-related fatigue was significantly higher (66/164 [40.2 %] vs 83/164 [50.6 %], p = 0.02). Granted holidays as requested (aOR, 0.54; 95 % CI, 0.37–0.79), being more confident about the future (aOR, 0.59; 95 % CI, 0.37–0.93) and a better perceived work-life balance (aOR, 0.42; 95 % CI, 0.27–0.65) were significantly associated with less symptoms.ConclusionThe second surge of the COVID-19 pandemic further drained the mental reserves of intensive care unit nurses, resulting in more work-related fatigue.     

Family support in intensive care units during COVID-19 visit ban: A multinational Delphi Study during first COVID-19 wave

ObjectivesThis study assessed opinions and experiences of healthcare professionals, former patients and family members during the first wave of the COVID-19 pandemic and focuses on challenges in family-centred care for intensive care unit patients and affected families.Research methodology/DesignA two-round modified Delphi process assessed the opinions and experiences of experts such as healthcare professionals, former patients and their families (n = 151).SettingThis study was conducted across four countries in Europe.ResultsIn total, 121 participants (response rate 80.13%) answered the first Delphi round; the second was answered by 131 participants (response rate 86.75%). Participants perceived family support in the intensive care unit as highly important during the COVID-19 pandemic. Enabling contact amongst patients, families and clinicians is regarded as essential to build hope and confidence in the treatment and the recovery process. The extraordinary situation led to the implementation of new communication structures such as video calls and websites.ConclusionA consensus was reached between healthcare professionals that virtual contact is essential for patients with COVID-19 and their families during visit restrictions. This should be done to establish confidence in the treatment.     

Knowledge,attitudes, and practice related to the prone positioning of patients among intensive care unit nurses working in COVID-19 units: A cross-sectional study in China

Background

An increasing number of studies persistently demonstrate that prone position ventilation can significantly improve the oxygenation index and blood oxygen saturation for most patients (70–80%) with acute respiratory distress syndrome (ARDS). Studies have also shown that the awake prone position was both safe and effective in helping patients with coronavirus disease 2019 (COVID-19) breathe spontaneously. However, the prone position is not widely adopted when treating patients with COVID-19 or ARDS from other causes. Basic knowledge, positive attitudes, and correct practices among the nursing staff are necessary to increase the use of prone positions, reduce the incidence of complications associated with prone positions, and improve the quality and safety of health care.

Aim

This study aimed to investigate the knowledge, attitudes, and practice of prone positioning of patients among intensive care unit (ICU) nurses working in COVID-19 units and provide suggestions for improvement.

Study design

ICU nurses were recruited from two designated tertiary hospitals for COVID-19 treatment in Shanghai, China, in April 2022, using convenience sampling. A questionnaire survey focusing on the dimensions of knowledge, attitudes, and practice of the prone position with 42 items, was conducted.

Results

A total of 132 ICU nurses participated. The scores on the overall questionnaire and the dimensions of knowledge, attitudes, and practice of prone position were 167.28 (95% CI, 161.70–172.86), 78.35 (95% CI, 76.04–80.66), 32.08 (95% CI, 31.51–32.65), and 56.85 (95% CI, 52.42–61.28) respectively. The overall average score was 79.66% (95% CI, 0.77–0.82). The results of multiple linear regression analysis showed that prior experience in treating patients with COVID-19 and professional titles were related to the level of knowledge, attitudes, and practice of prone position.

Conclusions

The ICU nurses strongly believed in the effectiveness of prone positioning, but their knowledge and practice levels need improvement. The experience in treating patients with COVID-19 and professional titles were related to the level of knowledge, attitudes, and practice of prone position. Nursing managers should ensure that ICU nurses are well trained in prone positioning and help enhance the knowledge and attitudes toward prone positioning to promote its widespread use.

Relevance to clinical practice

Clinical guidelines and in-service training modules need to be developed to promote the use of prone positioning and reduce prone position-related complications.     

Remote nursing training model combined with proceduralization in the intensive care unit dealing with patients with COVID-19

The shortage of personal protective equipment and lack of proper nursing training have been endangering health care workers dealing with coronavirus disease 2019 (COVID-19). In our treatment center, the implementation of a holistic care model of time-sharing management for severe and critical COVID-19 patients has further aggravated the shortage of intensive care unit (ICU) professional nurses. Therefore, we developed a short-term specialized and targeted nursing training program to help ICU nurses to cope with stress and become more efficient, thus reducing the number of nurses required in the ICU. In order to avoid possible human-to-human spread, small teaching classes and remote training were applied. The procedural training mode included four steps: preparation, plan, implementation, and evaluation. An evaluation was conducted throughout the process of nursing training. In this study, we documented and shared experiences in transitioning from traditional face-to-face programs to remote combined with proceduralization nursing training mode from our daily work experiences during the COVID-19 pandemic, which has shown to be helpful for nurses working in the ICU.     

Family member perspectives on intensive care unit in-person visiting restrictions during the COVID-19 pandemic: A qualitative study

BackgroundFamily member presence in the intensive care unit is important for patient well-being and recovery. Limitations to visits increase the risk of psychological distress in family members. During the COVID-19 pandemic, in-person visiting restrictions were introduced to prevent the spread of infection.PurposeTo explore the experience of in-person visiting restrictions imposed during the pandemic on family members of patients with COVID-19 admitted to an intensive care unit.MethodQualitative method with thematic analysis. Individual semi-structured telephone interviews were conducted.FindingsWe interviewed 21 family members. The results are presented in one overall theme with two main themes and five sub-themes. The theme ‘Striving for closeness even at a distance describes the experience of being kept at a physical distance when participants needed closeness the most. Even participants who were allowed in-person visits perceived a ‘distance’ due to personal protective equipment or because they could only view the patient from a window. Participants reported that contact with and information about the patient was of utmost importance. Visits were viewed as essential in providing for the patient’s wellbeing. Meaningful contact with the ICU team was vital for getting useful information. Phone calls became a lifeline, with digital aids such as video calls used occasionally to overcome the feeling of distance.ConclusionVisiting restrictions imposed during the COVID-19 pandemic made straightforward and comprehensible communication of information from the ICU team more essential to reduce family members’ perceptions of distance and exclusion from the intensive care unit.     

The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: A cross-sectional study

Background

During the Coronavirus disease 2019 (COVID-19) pandemic, hospital visits were suspended and video calls were offered to connect patients with their family members, especially toward the end of life (EoL).

Aim

The primary aim was to describe EoL care for COVID-19 patients dying in an intensive care unit (ICU). The secondary aim was to explore whether making video calls and allowing visits was associated with lower death-related stress in family members.

Design

Single centre cross-sectional study. The setting was the ICU of a COVID-19 center in northern Italy, during the first year of the pandemic. Data on patients who died in the ICU were collected; death-related stress on their family members was measured using the Impact of Event Scale-Revised (IES-R). The statistical association was tested by means of logistic regression.

Results

The study sample included 70 patients and 56 family members. All patients died with mechanical ventilation, hydration, nutrition, analgesia and sedation ongoing. Resuscitation procedures were performed in 5/70 patients (7.1%). Only 6/56 (10.7%) of the family members interviewed had visited their loved ones in the ICU and 28/56 (50%) had made a video call. EoL video calls were judged useful by 53/56 family members (94.6%) but all (56/56, 100%) wished they could have visited the patient. High-stress levels were found in 38/56 family members (67.9%), regardless of whether they were allowed ICU access or made a video call. Compared with other degrees of kinship, patients' offspring were less likely to show a positive IES-R score (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05 to 0.89).

Conclusions

During the first year of the COVID-19 pandemic, patients died without their family members at the bedside while on life-sustaining treatment. Stress levels were high in most family members, especially in patients' spouses. Video calls or ICU visits were judged favourably by family members but insufficient to alleviate death-related stress.

Relevance for Clinical Practice

During a pandemic, ICU access by patients' family members should be considered, particularly as the time of death approaches. Although generally appreciated by family members, EoL video calls should be arranged together with other measures to alleviate death-related stress, especially for the patient's spouse.     

Missed nursing care in the critical care unit,before and during the COVID-19 pandemic: A comparative cross-sectional study

ObjectivesTo describe and evaluate reported missed nursing care in the critical care context during different phases of the COVID-19 pandemic in Sweden.Research methodologyA comparative cross-sectional design was used, comparing missed nursing care in three samples: before the COVID-19 pandemic in 2019, during the second wave of the pandemic in spring 2020, and during the third wave of the pandemic in fall 2021.SettingThe study was conducted at critical care units at a university hospital, Sweden.Main outcome measuresThe MISSCARE Survey-Swedish version was used to collect data along with two study-specific questions concerning perception of patient safety and quality of care.ResultsSignificantly more overtime hours and number of days absent due to illness were reported during the pandemic. The nurse/patient ratio was above the recommended level at all data collection time points. Most missed nursing care was reported in items concerning basic care. The most reported reasons for missed nursing care in all samples concerned inadequate staffing, urgent situations, and a rise in patient volume. Most nurses in all samples perceived the level of patient safety and quality of care as good, and the majority had no intention to leave their current position.ConclusionThe pandemic had a great impact on the critical care workforce but few elements of missed nursing care were affected. To measure and use missed nursing care as a quality indicator could be valuable for nursing managers, to inform them and improve their ability to meet changes in patient needs with different workforce approaches in critical care settings.     

Nurse decision-making when managing noradrenaline in the intensive care unit: A naturalistic observational study

ObjectiveIntensive care nurses care for critically ill patients in a complex, fast paced environment. Management of noradrenaline (norepinephrine) is core business for intensive care nurses and nurse decision-making on noradrenaline is poorly understood. The study objective was to investigate decision-making processes nurses use when caring for intensive care unit patients receiving noradrenaline.Research MethodologyA qualitative exploratory design used the Cognitive Continuum Theory as a framework for naturalistic observations and interviews in two medical/surgical intensive care units in Melbourne, Australia.Main Outcome MeasuresObservational and interview data from field notes and audiovisual recordings were transcribed and coded to develop themes using reflexive thematic analysis.FindingsFourteen nurse and patient dyads were recruited to observational sessions from December 2019 to June 2021. Three major themes developed were Learning through doing; Individualised patient care; and Clinical expertise, with six supporting sub-themes. Nurses learned to manage noradrenaline experientially and developed titration and weaning strategies to support decision-making. Blood pressure targets and monitor alarms were used consistently to aid decision-making processes. Nurses were observed practicing across the cognitive continuum depending on knowledge structure, complexity of interventions, response time, and patient acuity.ConclusionExperiential learning of complex and high-risk interventions in the absence of guidelines or algorithms meant nurses developed their own titration and weaning strategies based on constant evaluation and re-evaluation of patient cues. Patient heterogeneity, cue ambiguity and a dynamic practice environment contributed to decision-making complexity that would benefit from development of evidence-based practice resources.Implications for Clinical PracticeNurses learn to manage noradrenaline through experiential learning, using blood pressure targets and monitor alarms to support decision-making when titrating and weaning noradrenaline. Nurses develop noradrenaline titration and weaning strategies to support decision-making in the absence of guidelines or algorithms. Supporting nurse decision-making and streamlining practice would reduce practice variation and cognitive workload.     

Ward nurses' experiences of the discharge process between intensive care unit and general ward

Background

Intensive care unit (ICU) discharges are challenging practices that carry risks for patients. Despite the existing body of knowledge, there are still difficulties in clinical practice concerning unplanned ICU discharges, specifically where there is no step‐down unit.

Aims and objectives

The aim of this study was to explore general ward nurses' experiences of caring for patients being discharged from an ICU.

Design and methods

Data were collected from focus groups and in‐depth interviews with a total of 16 nurses from three different hospitals in Sweden. An inductive qualitative design was chosen.

Findings

The analysis revealed three themes that reflect the challenges in nursing former ICU patients: a vulnerable patient, nurses' powerlessness and organizational structure. The nurses described the challenge of nursing a fragile patient based on several aspects. They expressed feeling unrealistic demands when caring for a fragile former ICU patient. The demands were related to their own profession and knowledge regarding how to care for this group of patients. The organizational structure had an impact on how the nurses' caring practice could be realized. This evoked ethical concerns that the nurses had to cope with as the organization's care guidelines did not always favour the patients.

Conclusions

The structure of the organization and its leadership appear to have a significant impact on the nurses' ability to offer patients the care they need.

Relevance to clinical practice

This study sheds light on the need for extended outreach services and intermediate care in order to meet the needs of patients after the intensive care period.